Meeting the Challenges of
VA Audiology Care in the 21st Century
Lucille B. Beck, Ph.D.
Chief Consultant for Rehabilitation Services, and Director,
Audiology and Speech Pathology Service
Disclaimer: The opinions expressed herein are solely those of the author and do not necessarily reflect the views or official policies of
the United States Government or the Department of Veterans Affairs.
VA Mission


To serve America's Veterans and their families with dignity and
compassion and to be their principal advocate in ensuring that
they receive the care, support and recognition earned in service
to this Nation.
VHA core missions:
—Health Care
—Graduate Medical Education
—Research
—Emergency Preparedness
VETERANS HEALTH ADMINISTRATION
st
21
Century VA Health Care
 People Centric
 Honor and Serve Veterans and Their Families
 Embrace VA Core Values of Compassion, Integrity, Respect, and Commitment
 Engage, Inspire, and Empower Employees
 Results Driven




Ensure Improved Access for All Veterans
Provide High-Quality Care and Exceptional Client Relationship Management
Leverage Technology and Adapt Business Processes with Agility
Demonstrate Leadership, Accountability, and Effective Results
 Forward Looking
 Communicate Widely and Effectively and Conduct Systematic Outreach and Collaboration
 Anticipate Veterans Needs and Be Pro-Active in Meeting Them
 Develop a VA Culture that Is Forward Looking, Innovative, and Veteran-Focused
VETERANS HEALTH ADMINISTRATION
VA Health Care
 Honor America's Veterans by providing exceptional health care that
improves their health and well-being.
 The largest integrated healthcare system in US:
— 152 hospitals
— 135 community living centers
— 209 veterans counseling centers
— 807 community based outpatient clinics (CBOC)
 $2 billion budget for prosthetics and sensory aids
 VHA manages the largest medical education program in the U.S, partnering
with 107 medical schools, 55 dental schools and 1,200 other schools. Over
109,000 health care professionals train in VA each year.
VETERANS HEALTH ADMINISTRATION
The Veterans We Serve…
 All Veterans
– 22.2 million Veterans and 35.2 million spouses and dependents of
Veterans
– Vietnam Era Veterans are the largest group (7.4 million)
– Women comprise 8.1% of Veterans
– About 20% of the nation's population, over 58 million people, are
potentially eligible for VA benefits and services.
 Veterans enrolled for VA health care
– 8.3 million
– 555,984 women Veterans enrolled
– 5,675,844 Veterans treated in FY11
VETERANS HEALTH ADMINISTRATION
Audiology Workload (FY2011)
1,512,699 encounters (+9% over FY10)
756,345 unique Veterans (+10% over FY10)
134,000 Veterans per month
3,979,345 procedures performed (+10% over FY10)
Source: VHA Support Service Center
VETERANS HEALTH ADMINISTRATION
Audiology Staffing (FY2011)
920 clinical audiologists (6% increase over FY10)
24 research audiologists
284 health technicians (audiology assistants)• 10% increase over FY10
305 sites of care
VETERANS HEALTH ADMINISTRATION
Graduate Education and Training
For Academic Year 2012-2013, VA awarded 62 Doctoral
Externships and 73 Doctoral Clinical Rotations.

― Externships are one-year advanced training experiences for 4th year
students. Rotations are 350-hour training for 1st, 2nd , and 3rd year
students.
 Competitive training site selection based
on standards of
excellence criteria:
―Training to full
scope of practice
―Emphasis on inter-professional education
Emphasis on evidence-based practice: defining quality and
outcomes of care

VETERANS HEALTH ADMINISTRATION
Leveraging Information Technology
 Equipment interfaces send audiometric data into the VA electronic health
record and hearing aid ordering system.
 Automated hearing aid and auditory device ordering and tracking system
(ROES).
−Automated outcome measures (IOI-HA)
−Outcomes analysis by age, degree of loss, hearing aid make/model or form
factor by facility, network, or national
−Ear impression scanning project (Boston Evaluation Project)
 National hearing loss repository (over 1.5 million audiograms stored)
― VA researchers have begun to mine the database and publish articles.
VETERANS HEALTH ADMINISTRATION
Hearing Aids
 Best technology anywhere.
 Digital Hearing Aid Contract (November, 2009):
– VA exercised the second option year under the contract in November.
 Other national contracts:
– Cochlear Implants
– Assistive listening devices
– Wireless devices and adaptors
– Ear molds (in development)
 DoD Centers use VA national contracts (2% of procurement)
VETERANS HEALTH ADMINISTRATION
FY2011 Hearing Aid Statistics
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596,443 hearing aids (+6% over FY2010)*
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Net procurement: $207 million
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Batteries: 59.3 million, $6.3 million

Repairs: 358,350, $14.5 million
*Reporting period: 9/25/10 to 9/24/11
Source: Commodity Sales Report, VA Denver Acquisition and Logistics Center
VETERANS HEALTH ADMINISTRATION
Hearing Aid Trends (1996-2011)
700,000
250
600,000
200
500,000
150
400,000
UNITS
SALES (000)
300,000
100
200,000
50
100,000
0
0
FY96 FY97 FY98 FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11
VETERANS HEALTH ADMINISTRATION
Contract Trends
Distribution of Procurement by Category:
Category
Group 1 (ITE)
Group 2 (BTE)
Group 3 (RIC)
Group 4 (CROS/BICROS)
Base*
34.52%
40.83%
16.82%
0.23%
Option I**
30.83%
32.51%
26.63%
0.20%
Items:
Average Cost:
Total Sales:
597,202
$348.15
$207,913,336
633,062
$344.39
$218,020,196
*Base Year 11/1/09 to 10/31/10
**Option I Year 11/1/10 to 10/31/11
Source: VA Denver Acquisition and Logistics Center
VETERANS HEALTH ADMINISTRATION
Hearing Aid Outcomes (IOI-HA)
Scoring: 1=poorest outcome, 5=best outcome
Q1 Use: 4.43
Q2 Benefit: 3.99
Q3 Residual activity limitation: 3.75
Q4 Satisfaction: 4.35
Q5 Residual participation restriction: 3.70
Q6 Impact on others: 3.82
Q7 Quality of life: 4.03
 Veterans’ self-perceived hearing difficulty ranged from 2.53
(moderate to moderately-severe) for mild HL to 1.39
(moderately-severe to severe) for profound HL.

VETERANS HEALTH ADMINISTRATION
Hearing Aid Outcomes (IOI-HA)
VA has collect over 30,000 outcomes.
HL
Mild
Mod
Mod-Sev
Severe
Profound
FY10 Average
FY11 Average
Q1
2.53
4.47
4.67
4.76
1.39
4.43
4.43
Q2
4.34
4.07
4.10
4.02
4.77
3.99
4.07
Q3
4.07
3.85
3.59
3.44
3.68
3.75
3.81
Q4
3.85
4.40
4.45
4.40
3.48
4.35
4.41
Q5
4.40
3.75
3.54
3.37
4.32
3.70
3.76
Q6
3.75
3.89
3.61
3.40
3.65
3.82
3.85
Norm*
4.50
3.52
3.19
3.84
3.38
3.38
Norm**
3.73
3.39
3.40
3.20
3.57
3.79
*Moderately-severe to severe perceived hearing difficulty group data
** Mild to moderate perceived hearing difficulty group data
VETERANS HEALTH ADMINISTRATION
Q7
3.89
4.05
4.06
4.06
3.29
4.03
4.06
3.68
3.19
Q8
4.05
2.18
1.71
1.43
3.61
2.34
2.34
Growth in Tele-Rehabilitation
VETERANS HEALTH ADMINISTRATION
Distribution of Tele-Rehab Services
VETERANS HEALTH ADMINISTRATION
Growth in Tele-Audiology
VETERANS HEALTH ADMINISTRATION
Audiology Telehealth Pilot Program
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Community Based Outpatient Clinic (CBOC )hearing aid teleprogramming using remote control software with hearing aid
fitting software at 10 pilot sites (rural locations)
– Telehealth Technician staffing
All sites equipped with telehealth equipment and software
− Telehealth cart (video conferencing, dual monitors, PC)
− Equipment (audiometer, immittance, real-ear, video
otoscope, programming interfaces)
Pilot sites will collect outcome and satisfaction data, provide
“lessons learned”, and contribute to a national toolkit to
facilitate national roll-out.
VETERANS HEALTH ADMINISTRATION
VA Innovation Initiative (VAi2)
 VAi2 is a flagship program designed to tap the talent and expertise of
individuals both inside and outside government to contribute new ideas
that produce visionary solutions to advance VA’s ability to meet the
challenges of becoming a 21st-century organization.
 Audiology Telehealth solutions in the FY2011 VA Innovation Initiative
(VAi2) competition, announced on February 15, 2011.
 VAi2 is now working with the winning innovators to refine their proposals
into well-defined projects with milestones, deliverables, and a pilot phase.
http://www.va.gov/vai2/
VETERANS HEALTH ADMINISTRATION
VA Tinnitus Management
 Tinnitus requires a holistic, patient-centered, inter-disciplinary approach,
significant association with brain injury, noise exposure, hearing loss, ear
disease, many medical conditions, and medications.
 Progressive Tinnitus Management (PTM)* is a five-level progressive treatment
approach:
‫־‬Triage and referral
‫־‬Auditory evaluation
‫־‬Structured interviews
‫־‬Counseling and group education
‫־‬Tinnitus evaluation
‫־‬Individualized management
*Developed by the National Center for Research in Auditory Rehabilitation
VETERANS HEALTH ADMINISTRATION
Defense Hearing Center of Excellence
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HCE serves as the ‘unified voice’ for the DoD, VA and other federal agencies regarding the
prevention, diagnosis, mitigation, treatment, rehabilitation, and research of hearing loss and
auditory system injuries.
Air Force has lead responsibility for development.
Joint Hearing and Auditory System Injury Registry (JHASIR) Concept of Operations (CONOPs)
was approved. Efforts are underway to integrate existing DOD and VA audiogram data
systems.
VA Audiology Program Office is collaborating closely with DOD on development of HCE.
VETERANS HEALTH ADMINISTRATION
Military Separation Health
Assessment

Legislation (NDAA ,2005) requires service members to receive
a physical evaluation at separation.

Audiogram is a mandatory part of the Separation Health
Assessment, to be completed within 6 months of separation.

Audiograms will be stored in a DoD hearing surveillance
database called DOEHRS-HC.
VETERANS HEALTH ADMINISTRATION
Auditory Disabilities
Condition
Number of Veterans
Tinnitus
744,871
Hearing loss
672,410
• 1,525,066 Veterans have disabilities in the Auditory Body
System, 12.1% of all disabilities
• 92,260 veterans began receiving compensation benefits for
tinnitus and 63,583 veterans began receiving benefits for
hearing loss in FY2010.
Source: VBA Annual Benefits Report, 2010
VETERANS HEALTH ADMINISTRATION
Audiology C&P Exams
AUDIO EXAM (hearing loss & tinnitus) is the second most commonly requested exam after
general medical exams. Over 156,000 audiology C&P exams performed in FY2011 (12% of all
C&P exams) at a cost of $42 million.
Specialty
General Medical
Audiology
Psychology
Orthopedics
Psychiatry Consult
Psychiatry Ind
Mental Health Ind
Neurology
Optometry
Ophthalmology
Exams
473,835
156,554
71,005
50,516
43,736
38,287
34,625
22,510
19,299
17,690
Veterans
390,444
141,160
65,086
45,859
37,977
35,211
32,098
20,080
18,356
16,389
VA performed 1.6 million C&P exams on over 1.1 million Veterans and active duty Service
members at a cost of $548 million.
VETERANS HEALTH ADMINISTRATION
Compensation Trends
900000
800000
700000
600000
500000
Hearing Loss
400000
Tinnitus
300000
200000
100000
0
2003 2004 2005 2006 2007 2008 2009 2010 2011
VETERANS HEALTH ADMINISTRATION
Thanks for Listening
With malice toward none, with
charity for all, with firmness in the
right as God gives us to see the right,
let us strive on to finish the work we
are in, to bind up the nation's
wounds, to care for him who shall
have borne the battle and for his
widow and his orphan, to do all
which may achieve and cherish a just
and lasting peace among ourselves
and with all nations.
Abraham Lincoln, Second Inaugural
Address, March 4, 1865
VETERANS HEALTH ADMINISTRATION